vetoryl or alternative treatment?

[rock2avenged]

hello
this is my first post on here and after other peoples opinions on what to do next.....I am mum to a 12 year old Labrador called ebony....ebony was diagnosed with diabetes, cushings and a thyroid problem at the age of 7, its been hard work managing all the conditions but we have done really well thus far. A couple weeks ago I noticed that she became out of sorts, she started to have accidents around the house/ leaving puddles on the kitchen floor. At night she began pacing and panting and acting strange, keeping us awake all night. I thought that here vetoryl medication made need changing so booked her in for acth test. when the results came back I was surprised to find that the level were too low and after the vet spoke to the drug company I was told to stop the vetoryl for 7 days. I have been told to restart on a lower dose, she was on 60mg, so reduce to the 30mg dose and then have the acth test repeated after she is on the new dose for 14 days. The thing is ebony is getting so upset with the visits to the vets, they are no longer able to get blood samples from the leg and have started to use the jugular which worries me. when she visits the vets it makes her very stressed and so I am thinking of not continuing with the vetoryl and trying an alternative therapy. she was also found to be suffering from a water infection and has also got an eye ulcer that she is being treated for, both of which are know to be side affects of using vetoryl. Since stopping the vetoryl she is sleeping better, she looks healthy and eats well. her water intake has not increased.
so what to do next?

[Squirt's Mom]

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[Harley PoMMom]

Hi and welcome to you and Ebony,

So sorry for the reasons that brought you here but glad you found us.

I was wondering if you could give some additional information about Ebony as that would help us to provide you with more meaningful feedback. Could you get copies of all tests that were done on Ebony and post any abnormal results? We are especially interested in any diagnostic or monitoring tests for Cushing's, this would include a LDDS, ACTH stimulation, or an UC:CR. Also, could you tell us what symptoms Ebony was displaying that led you or your vet to test for Cushing's in the first place? Is Ebony on any other herbs/supplements/medications? How much does Ebony weigh? Does Ebony have any other health issues?

I apologize for all these questions but the more we know about Ebony the better we will be able to help you help Ebony. ok? ;)
Looking forward in hearing more about sweet Ebony.

Hugs, Lori

[rock2avenged]

hi lori
I am not sure if our vet gives out copies of test results....although I have never asked, I just know the last acth showed levels too low. ebonys current weight is 24.3kg. the last two times she was weighed at the vets her weight had increased slightly both times which I was happy about as over the last few years she has lost a lot, I think her original weight was approx 33kg. she has been on the 60mg dose of vetoryl for approx. 4 years now and it has worked well up till now. symptoms pre diagnosis were as follows, hair loss, lethargic (we were unable to walk further than the end of the street), high water intake and going toilet in the house ( although this could also have been caused by the diabetes) . diagnosis of all three conditions were made very close together and things did not become stable until she was receiving treatment for all three. she currently has 15units of caninsuline twice daily for the diabetes which is currently unstable with her sugar levels reading between any where between 9 and 22 which I have been checking every other day, she also takes 1.5 tablets of forthyrone twice a day for the thyroid which is currently stable. ebony has cateracts and has been blind for the last four years, she now also has some hearing loss.The vet also believes that she is suffering from dementia, she gets very confused. we give her cod liver oil to help with joints and coat. I don't want you to think all is bad for her, I know she is still happy and still loves a walk and bounces when its breakfast and dinner time and she loves to hunt for biscuits that we chuck around the kitchen for her to find, although her sense of smell seems to be rubbish and can take her a while to find them.

[Harley PoMMom]

Cushing's can be difficult to diagnose and when other non-adrenal illnesses are present the results from all tests for Cushing's can be skewed. It would really help us a great deal if you could get copies of all ACTH stimulation tests with their timelines and post that information here. Unfortunately many times we have seen a vet incorrectly interpret the results of an ACTH stimulation test. :(:mad:

I, also, wanted to provide you with a link to our sister site that deals with canine diabetes, the wonderful folks there can help a great deal with Ebony's diabetes: http://www.k9diabetes.com/forum/ I strongly urge you to join there too.

We have seen some dog's cortisol levels drop while being treated with the same dosage over a period, so it could be that this is what happened to Ebony but we really need to see those ACTH results to confirm this.

If you have any questions at all please do feel free to ask them, and know we will help in any way we can.

Hugs, Lori

[LtlBtyRam]

Hello and welcome to a forum full of PAWSOME folks.
Angela

[molly muffin]

Hello and welcome from me too.

We have seen people come to the forum, whose dogs have been on vetroyl (trilostane) for a couple years and suddenly the cortisol is going too low. After 4 years, it is certainly possible that this is what has occurred with Ebony. If so, it could also have thrown the diabetes off too.

You wouldn't restart treatment until and unless the symptoms of cushings return. If so, the you'd start at the lower dose. Would they come out to your car and take do the blood draw there?

Yes, vets in the UK can give the tests results to you. We've had other members acquire them. Just tell them you want to keep a file on all tests leading up to, during this period and from now on, so you can better monitor her treatment and make decisions about what should or shouldn't be done.

It does sound like Ebony is a happy gal. You would know best about that, but dogs can over come many trials and burdens in their life and adapt, remaining quite happy. One of our members, has a two blind dogs currently, both happy and healthy. Another one has a very happy blind pug, so we understand that this happens and you just continue on.

welcome to the forum
Sharlene and Molly Muffin

[rock2avenged]

it has now been seven days with no veteroyl......and I cant believe the change in ebony.....she is back to her old self. she has so much more life in her and wants to play . Her sugar levels have also seemed to have settled, in fact I might even get away with lowering her caninsuline dose. I am supposed to be putting her back on the lower dose 30mg vetoryl tomorrow, but at this moment in time, I don't think so.

thanks for all the messages

sue and ebony xx

[frijole]

I am at work so can't read back.. could it be that your dog only had diabetes and not cushings? I agree - don't start dosing tomorrow. Hopefully others with time can read back and comment. Kim

[rock2avenged]

ebony was diagnosed with diabetes over five years ago , her sugar levels at the time were dangerously high in the 30's but insulin had little effect and we put the dose up and up and still did little good. a couple of months after the diabetes was diagnosed she was diagnosed with cushings and put on vetoryl 30mg capsules, they helped and her sugar levels did come down in to the late teens. then a couple of months later she was diagnosed with a thyroid problem and put on forthyrone tablets and soon after starting this medication her diabetes became stable. ebony stayed on the 30mg vetoryl for twelve months then it was increased to the 90mg which she has been on for the last four years, her thyroid medication has always stayed the same but insulin dose has recently needed to be increased little by little over the last couple of months I guessed it was the cushings upsetting the balance so brought forward the acth stim test thinking her vetoryl would need putting up not going down.

[Harley PoMMom]

I think Ebony's thyroid issue was the problem regarding the insulin resistance.

A renown endocrinologist, Dr. Mark Peterson, has written an article on his blog about this:
My Bottom Line:

The results of this study show that hypothyroidism does indeed cause substantial —even marked—insulin resistance, as evidenced by an almost 5-fold decrease in insulin sensitivity, compared with the insulin sensitivity in euthyroid dogs (4). The pathogenesis of insulin resistance appears to be multifactorial, with high serum GH and IGF-1 concentrations probably contributing. In addition, the role of visceral fat on glucose metabolism may also be important in the development of insulin resistance in hypothyroid dogs

Hypothyroid-Induced Insulin Resistance in Dogs (http://endocrinevet.blogspot.com/2012/07/hypothyroid-induced-insulin-resistance.html)


Since Ebony is doing and feeling so much better while being off the Vetoryl, if this were me, I would not restart the Vetoryl.

Hugs, Lori

[rock2avenged]

vet has just emailed me through ebonys last results....have not got a clue what I am looking at. results as follows


post acth therapeutic monitoring result 66.000nmol/l range 27.6-165.5

thyroxine 24.000nmol/li 10.3-50.1
cortisol 113.000nmol/l 27.6-165.5
cortisol 40.000nmol/l 27.6-165.5
sodium comment Hi 1% 161.000nmol/l 144-160
potassium 3.600mnol/l 3.5-5.8
chloride 116.000mnol/l 109-122
Na:K 44

and thanks for the info lori....just had a read xx

[molly muffin]

Conversion of ACTH from nmol to ug

Pre 113.000nmol/l 27.6-165.5 = 4.095 ug
POST 40.000nmol/l 27.6-165.5 = 1.449 ug

Dechra the manufacturer of vetroyl does not recommend a pre or post result below 1.54 Ebony is definitely too low in her post result and that is probably why you are seeing the sodium start to go too high and the potassium to be at the very low end of the acceptable range.

Recommendation for cortisol amounts while under treatment are not the same as results considered normal by the labs prior to treatment.

I wouldn't give Ebony any vetroyl at this point unless you see symptoms coming back and then would start at a lower dose.

This could also be part of the reason that insulin is not optimal.

Sharlene and Molly Muffin

[frijole]

This number concerns me. The pre number should not be higher than the second number.

Pre 113.000nmol/l 27.6-165.5 = 4.095 ug
POST 40.000nmol/l 27.6-165.5 = 1.449 ug

[labblab]

Actually, I am totally confused because there are three different cortisol levels listed, and the one that is marked "post ACTH therapeutic monitoring" result is 66 nmol/l (or 2.4 ug/dl). So we really don't know which/either any of those other two are "pre" or also "post" ACTH results. It will really help if you can find out whether those additional cortisol levels were resting cortisol levels taken at different times or whether either represent cortisol levels after injection of a stimulating agent (ACTH stimulation test).

Marianne

[molly muffin]

You're right Marianne, I didn't even see that Really. Did but didn't if you know what I mean. My mind saw a pre and a post, but yea, with 3, hard to know which is which.

Sharlene and Molly Muffin

[rock2avenged]

hi guys
sorry for confusing you.....it was the way the notes were written and the way I was looking at them. on closer inspection the top result if from the previous acth test which was baseline cortisol of 120.000nmol/l and post acth of 66.000nmol/l. so the newest results were 113.000nmol/l and 40.000nmol/l. so I take it previous test was not good either?

sue

[labblab]

I really, really have to wonder whether your vet's office is mistakenly labeling the blood samples when they are submitted for ACTH analysis. The "pre" number is typically expected to be the lower of the two since the "post" sample is drawn after the stimulating agent has been injected. It is possible for the "post" to be a bit lower, and when this happens, it is indeed the case that the worry is that the adrenals are being oversuppressed by the Vetoryl and the dog's ability to store cortisol is being compromised.

However, in Ebony's case, the "pre" numbers on both occasions are significantly higher than the "post," and that is very, very unusual. Which...leads me to believe that the samples may have been reversed with both tests. If so, these would be your "post" results instead, and they would actually be nicely within the acceptable monitoring range (if both "posts" are indeed around 120 nmol/l or 4 ug/dl).

However, the bottom line to all of this is that if Ebony seems to be doing well (in fact, better) off the Vetoryl altogether, I don't know that I would be in any hurry to start back up with the medication. There is still a lot to be learned about the action of the drug, and it is possible that Ebony's Vetoryl treatment may be resulting in some longterm adrenal suppression such that she can take a break from the drug without seeing any immediate rebound in cortisol or Cushing's symptoms. If it were me, I think I'd welcome the break and take a "wait-and-see" approach for now.

Marianne

[frijole]

I checked in from work and am so happy to see Marianne is on the case. :D Kim

[rock2avenged]

this has all got me a bit worried. our local vets has a lot of comings and goings and a lot of the vets are newly qualified. last visit I managed to catch the senior partner who does not visit our town very often as I wanted him to look over ebony as I wasn't happy with the vet I saw at the time she went in for her acth test. ebony has an eye ulcer, which I understand can be a side affect of vetoryl, she has had the ulcer for a number of weeks, I was told it would be a long job healing. when she went in for the day for testing they checked her all over and I was told by the vet that the ulcer had gone and to stop treatment, I wasn't convinced and carried on with the eye dops anyway. went back for second opinion with the senior vet and I was right the ulcer was still there. the senior vet also looked at her test results and agreed with stopping the vetoryl as results were too low and said looking back that this was also the case with past tests. which has never been mentioned to me.

[molly muffin]

Just wanted to check in and see how Ebony is doing. Hoping that all is well.

Sharlene and Molly Muffin